Abstract

A successful surgical outcome for patients with shoulder instability requires a complete preoperative evaluation, a thorough diagnostic arthroscopy to evaluate for concomitant co-pathology, and an effective postoperative therapy program tailored to the repair strategy. In addition to the Bankart lesion, the surgeon must be aware of other co-pathologies such as the HAGL lesion, the ALPSA lesion and SLAP tears, all of which may occur in concert with capsular pathology and which present as potential barriers to a successful outcome. We have previously described the use of a posterolateral arthroscopic portal, 4 cm lateral to the posterolateral corner of the acromion. This portal simplifies and improves anchor placement, trajectory, and anatomic capsulolabral repair of the inferior glenoid. In this case, we perform a hybrid repair using the posterolateral portal to place the first suture anchor at the 6 o’clock position on the glenoid and the mid-glenoid portal to place two labral tape knotless anchors.

Case Overview

Focused history

Obtain a history which includes past injury, trauma, and/or repetitive motions.

Has the patient dislocated? If so, how many times? What was the mechanism? How strong was the force required to dislocate?

What limitations in activity have occurred? Is pain or instability present at rest? Does it interfere with sleep?

What prior treatments, if any, has the patient already tried (i.e. physical therapy, rest, anti-inflammatory medication) and to what degree did these help?

Physical exam

Palpate the shoulder for tenderness and document range of motion compared to the contralateral extremity. Differences between active and passive motion may indicate pain or capsular contracture.

Test for impingement to determine whether rotator cuff tendinitis is present. If weakness is present during strength testing, it may be from deconditioning or from underlying rotator cuff or deltoid pathology.

Tests for anterior instability

Apprehension sign – performed with patient supine and the arm forward flexed 90 degrees and the elbow flexed 90 degrees. The patient exhibits apprehension when an anterior force is applied to the shoulder

Relocation sign – the patient’s apprehension decreases when a posterior, supporting force is applied to the shoulder

Sulcus sign – an inferior force is applied to the shoulder with the patient standing, arm at their side. Appearance of a depression below the acromion indicates a positive sulcus sign

Imaging

Evaluation should begin with a complete trauma series of the shoulder including a true AP, scapular Y and axillary views. A West Point view can be helpful in evaluating glenoid bone loss and Stryker view is best for seeing a Hill-Sachs lesion, if present.
MRI is the modality of choice for evaluating the presence and extent of a labral tear. Intra-articular contrast will increase the sensitivity and specificity.

Axial T1 Weighted

Axial Proton-density fat saturation

Coronal Proton-density fat saturation

Natural history

This patient developed anterior instability after traumatic dislocation in an anterior-inferior direction. Instability as the result of trauma almost always results from a labral tear which requires surgical intervention. Associated injuries may include superior labrum anterior-posterior (SLAP) lesions, rotator cuff tears, Hill-Sachs lesions, an Anterior Labral Periosteal Sleeve Avulsion (ALPSA) lesion, Humeral Avulsion of the Glenohumeral Ligament (HAGL) lesion, and a Glenoid labral articular defect (GLAD).

Options for treatment

The options for treatment are conservative treatments including physical therapy and NSAIDs. Open surgical repair is still considered the gold standard, however arthroscopic management has certain advantages over open repair in the hands of a skilled surgeon. Open repair is indicated for a bony Bankart lesion greater than 20% of the glenoid. HAGL lesions are technically challenging to address arthroscopically and can be considered an indication for open repair.

Rationale for this procedure

An arthroscopic repair compared to an open surgical procedure results in a shorter recovery and rehabilitation time, a decreased risk of joint infection, less risk of bleeding and the ability to visualize the entire shoulder joint with the arthroscope. An arthroscopic procedure also results in less pain during the recovery process.

Special considerations

Patients with large bone defects or developmental abnormalities of the shoulder with dysplasia may require a more extensive, open approach. Normal neurologic function of the upper extremity is a necessity for a successful outcome. Failure of the patient to comply with the recommended postoperative restrictions and therapy protocols could result in a failure of the repair necessitating reoperation. Other complications from failure to follow the postoperative protocol could lead to infection, shoulder stiffness, or an otherwise sub-optimal result.

Discussion

Technical advances in arthroscopic instability repair have led to outcomes approaching those of open surgical repair. Our approach to the arthroscopic Bankart uses the posterolateral portal described above in the technique section as the standard arthroscopic portals provide insufficient visualization and instrumentation access to the inferior glenoid.2 The advantages of the posterolateral portal are enhanced ability to place anchors in the inferior glenoid at an improved trajectory, improved anteroinferior knot tying, facilitation of anteroinferior labral repair, and anatomic reduction of the inferior glenohumeral ligament.

Benefits and Limitations of Posterolateral Portal

In 2002 Davidson and Rivenburgh3 first described the 7 o’clock posterolateral portal in cadaveric shoulders as a way to obtain improved working access to the inferior glenoid. This portal entered the glenohumeral joint through the teres minor tendon at a safe distance from the suprascapular nerve and artery (28 ± 2 mm) and from the axillary nerve and posterior circumflex humeral artery (39 ± 4 mm).3 Difelice et al4 found in a cadaveric study that a similarly placed posterolateral portal had a distance of 34 ± 5 mm from the axillary nerve and 29 ± 3 mm from the suprascapular nerve. These studies also found that arm position did not change the distance from the portal to the neurovascular structures.3,4 The reported uses of the posterolateral portal include arthroscopic management of humeral avulsion of the glenohumeral ligament,5 posterior instability,6 and Bankart lesions.

Outcomes

Outcomes of arthroscopic repair of Bankart lesions are favorable. Netto et al8 reported the results of a randomized controlled trial of 50 adult patients under 40 years of age with traumatic anterior shoulder instability and the presence of an isolated Bankart lesion confirmed by diagnostic arthroscopy, randomly assigned to receive open or arthroscopic treatment of an isolated Bankart lesion. The primary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires. 42 patients were evaluated after a mean follow-up period of 37.5 months. On the DASH scale, there was a statistically significant difference favorable to the patients treated with the arthroscopic technique, but without clinical relevance. There was no difference in the assessments by University of California, Los Angeles and Rowe scales. There was no statistically significant difference regarding complications and failures, as well as range of motion, for the two techniques.
Waterman et al retrospectively analyzed the outcomes of 3,854 active duty military patients who underwent Bankart repair between 2003 and 2010 with most procedures having been performed arthroscopically (n=3,230, 84%).9 Patients were predominantly men (n=3,531, 92%), and the mean age was 28.0 years (SD, 7.5 years). Younger age, open repair, and inpatient status were found to be risk factors for surgical failure. Patients who underwent arthroscopic Bankart repair had a significantly lower surgical failure rate (4.5%) than patients who underwent open anterior stabilization (7.7%).

Possible Complications

Recurrent instability

Stiffness

Infection

Neurovascular injury

Equipment

Spectrum MVP suture passer ConMed Linvatec, Largo, FL

3.0mm Suture Tak Anchors, Arthrex, Naples, FL

2.9mm PEEK Knotless Labral Tape Anchor, Arthrex, Naples, FL

0 PDS Sutures, Ethicon, Somerville, NJ

Disclosures

The author has no financial relationship with any of the companies mentioned in this article.

Statement of Consent

The patient undergoing the filmed procedure gave consent to being filmed for this video article and is aware that it may be published online.

Anesthesia

Interscalene regional nerve block given in the preoperative holding area

General anesthesia given in the Operating Room

Patient Positioning

Place the patient in the lateral decubitus position

Ensure that all bony prominences are padded

The shoulder is then placed in 40 degrees of abduction, 20 degrees of forward flexion, and 10-15 pounds of balanced traction

The shoulder is prepped and draped in the usual sterile fashion

Portal Placement and Diagnostic Arthroscopy

The glenohumeral joint is first injected (posteriorly) with 50 mL of sterile saline through an 18-gauge spinal needle. Alternatively, the soft spot is identified in thinner patients and can be a relatively easy access point for entry in the absence of saline insufflation.

A posterior portal is established 1 cm distal and 1 cm lateral to the standard posterior portal that is used for routine shoulder arthroscopy.

This portal is often in line with the lateral border of the acromion.

Placement of this portal more laterally than typical allows adequate access to the posterior glenoid rim for later anchor placement.

An anterior portal is established high in the rotator interval via an inside-out technique with a switching stick.

As an alternative, this portal can be established with a spinal needle via an outside-in technique.

The anterior switching stick is then replaced with a 7mm distally threaded clear cannula.

Through the posterior portal, a diagnostic arthroscopy is performed.

The articular surfaces of the glenohumeral joint are inspected for chondral damage.

The posterolateral aspect of the humeral head is inspected for any Hill-Sachs lesions (which may indicate combined anterior instability).

The anterior and inferior labrum is inspected and the glenohumeral ligaments are visualized. The biceps tendon and superior labrum are probed to detect any pathology.

Concomitant SLAP tears are common with posterior instability.

The rotator cuff is inspected (including the subscapularis tendon).

A switching stick is then placed in the posterior portal and replaced with an additional 7mm distally threaded clear cannula.

The arthroscope is then replaced into the anterior cannula for viewing; it remains there for the rest of the operation.

The posterior capsule and labrum are inspected and probed.

The anterior humeral head surface is inspected for any reverse Hill-Sachs lesions, which may indicate macroinstability.

Typically the posterior labrum is detached and the capsule attenuated, requiring the placement of suture anchors.

Prepare and Mobilize Labrum

An arthroscopic rasp or chisel is used to mobilize the labrum from the glenoid rim.

The rasp is then used to debride the capsule to create an optimal environment for healing.

A motorized shaver or burr can be used on the glenoid rim to achieve a bleeding surface for healing.

Elevate Capsule, Labrum and Prepare Glenoid

An arthroscopic rasp or chisel is used to mobilize the labrum from the glenoid rim.

The rasp is then used to debride the capsule to create an optimal environment for healing.

A motorized shaver or burr can be used on the glenoid rim to achieve a bleeding surface for healing.

Attach Labrum to Glenoid

Suture anchors are placed along the articular margin, not the glenoid neck, for the repair and capsular plication.

Typically we use three 2.3mm Bio-Raptor suture anchors with no. 2 Ultrabraid (Smith and Nephew, Andover, MA). A number of other commercially available anchors can be used in a similar fashion.

The anchor pilot holes are predrilled and the anchor is inserted with a mallet.

The anchor is placed so that the sutures are perpendicular to the glenoid rim. This facilitates passage of the most posterior suture through the torn labrum.

The anchors are evenly spaced on the posterior glenoid rim for a symmetric repair.

A 45 degree Spectrum Hook (Linvatec Corp., Largo, FL) loaded with number 0 PDS suture (Ethicon, Somerville, NJ) is used to shuttle the suture through the capsule and labrum.

The suture hook is delivered through the capsule (if a plication is warranted) and under the torn labrum at the articular margin of the glenoid.

An inferior-to-superior direction is used for this maneuver to achieve a small capsular plication.

This direction of suture passage is aimed at restoring tension to the posterior band of the inferior glenohumeral ligament.

Patients with significant instability clinically may require a more aggressive plication than those with isolated pathology to the glenoid labrum.

The PDS is fed into the glenohumeral joint and the passer is withdrawn.

A suture grasper is then used to withdraw the most posterior suture in the anchor and the PDS that has been delivered through the capsulolabral complex.

Grabbing the more posterior suture helps to ensure that the suture limbs do not become entangled.

The PDS is then fashioned into a single loop and tied over the braided Ultrabraid suture.

The opposite limb of the PDS is then pulled and the Ultrabraid is delivered through the labrum and capsule.

Additional sutures are then shuttled in similar fashion to complete the repair.

After each suture has been shuttled through the capsular-labral complex, it is tied using arthroscopic knot tying techniques.

Note: We prefer to begin our repair inferiorly and advance superiorly up the posterior glenoid rim. In this way, the tension achieved with each advancing stitch can be assessed.

An arthroscopic awl is used to penetrate the posterior bare area of the humerus in an effort to achieve punctate bleeding to augment the healing response.

The posterior cannula is then withdrawn to just posterior to the level of the capsule and the posterior capsular incision is closed with a PDS suture.

A crescent Spectrum suture passer is used to penetrate one side of the capsule by the posterior capsular incision, and the suture is threaded into the joint.

The suture is retrieved through the opposite side of the incision with a penetrator and an arthroscopic knot is tied down to close the portal.

Varying the distance of the suture from the portal incision allows additional tension to be applied to the posterior capsule.

Inspect Repair / Test for Stability

Inspect the integrity of the repair.

If additional plication is warranted (such as in multidirectional instability), additional sutures can be placed in the rotator interval or anterior capsule as described elsewhere in this text.

The skin portals are closed with interrupted nylon suture and the patient is placed in a sling that allows slight abduction.